YOU might’ve been told by a bed partner that you snore, but did you know that snoring is one of the symptoms of sleep apnea?

Sleep apnea is a breathing disturbance that is usually characterised by intermittent, cyclical cessations or reduction in airflow while you sleep. In other words, you have one or more pauses in breathing or shallow breaths while you sleep and it can occur 30 times or more per hour.

Speaking with the Jamaica Observer in a recent interview, Dr Deborah Douglas, chief resident, anaesthesia and intensive care, at the University Hospital of the West Indies, said there are different types of sleep apnea, namely obstructive, central and mixed.

She explained that the terms apnea and hypopnea come up when looking at obstructive sleep apnea, which is the most common type of the three.

“Apnea is actually the complete cessation of airflow, and for it to be significant it should be greater than 10 seconds,” Dr Douglas said. “Hypopnea is actually a reduction in the airflow of about greater than 50 per cent, and again it has to be greater than 10 seconds for it to be significant.”

Thie chief resident said obstructive sleep apnea occurs when someone has the cessation or reduction of the airflow, but there is persistent respiratory effort, that is, you are still making an attempt to breathe.

Central sleep apnea, on the other hand, has more to do with the brain, according to Dr Douglas, and the absence of any respiratory effort that may be as a signal from the brain to the respiratory muscles. And she said mixed sleep apnea is an interplay between the two.

Though a pulmonologist would make the official diagnosis for sleep apnea through a sleep study or polysomnography, Dr Douglas explained that, as an anaesthetist, she sees a lot of patients who turn up for surgical procedures and present with symptoms of the condition, the majority of whom are undiagnosed.

“It is such a vicious cycle from just lying down and snoring,” she said.

The other symptoms she outlined are: Excessive daytime sleepiness, witnessed pauses in breathing whilst asleep, poor memory or concentration, gastroesophageal reflux disease, mood or personality changes, morning headaches, and impotence.

She told Your Health Your Wealth that there are currently no local studies looking at the incidence of patients with obstructive sleep apnea, but said, based on international studies, about two to four per cent of patients have obstructive sleep apnea.

She explained that obstructive sleep apnea may be classified as mild, moderate or severe based on the polysomnography, which is the gold standard for diagnosis.

Diagnosis

Dr Douglas said that the polysomnography records brain activity and eye movement, the oxygen level in the blood (oxygen saturation), heart rate, breathing effort and respiratory rate, airflow in and out your lungs, and electrical activity of muscles.

“The ultimate goal of the study is to grade the severity of a patient’s condition, therefore assessing their risk, and this is classified according to the Apnea Hypopnea Index (AHI), and from that recommend forms of therapy,” she explained.

She said that the AHI index tells whether a patient is mild, moderate or severe.

“If you have five to 15 incidence per hour then you are mild. If you have between 15 and 30 then you are moderate, and greater than 30 it is severe,” she said.

But admitting that not everyone might be able to afford a to do a sleep study, Dr Douglas shared that there are some risk factors that would cause the anaesthetist or pulmonologist to be concerned that the ‘stop bang’ questionnaire could help to determine whether a patient is high risk for obstructive sleep disorder.

S: Do you snore loudly?

T: Do you feel tired?

O: Has anyone observed that you stop breathing during sleep?

P: Do you have high blood pressure?

B: What is your body mass index? (Obesity is a major risk factor.)

A: How old are you/are you over 50 years?

N: What is your neck circumference? (If you neck circumference is greater than 40 centimetres then that also cues us into thinking that we really should look out for this condition.)

G: Gender, are you male?

“Now if you satisfy greater than or equal to three of those, then you are said to be high risk for obstructive sleep apnea, and less than three you are low risk,” the chief resident said.

She pointed out the obstructive sleep apnea affects more men than women.

“Men are actually more predisposed than women, actually two to three times more predisposed, and the thinking is that their airway actually has more fat deposition so they are more predisposed to a smaller airway than the females, and they also tend to have a longer airway as well, so they have more airway to ‘collapse’.”

Dr Douglas explained that the airway is specifically the upper airway, which consists of our nose, nasal passage, the sinuses, the pharynx, and the larynx.

“The area between the roof of the mouth, which is the hard palate and the voicebox at the back of the throat is pretty much just muscle and soft tissue, there is no real rigid or boney support, so it is very much predisposed to collapse,” she said.

associated Conditions

“Persons who have mild obstructive sleep apnea may or may not have long-term sequelae (a condition from pre-existing illness), but definitely once you start going into the realm of moderate and severe, you tend to be more predisposed to hypertension, you tend to be predisposed to heart disease, you can be predisposed to abnormal heart rhythm… you are again at high risk of having a first-ever stroke event, you are again at risk of developing type two diabetes and also obstructive sleep apnea is strongly linked to gastroesophageal reflux disease,” Dr Douglas told Your Health Your Wealth.

“So you start with the airways and then most other systems are affected,” Dr Douglas shared.

“So many people snore and unbeknownst to them, these other issues are happening and they do not even think twice about it.

“So you may wake up with headaches every morning and you just take your medication and go about your business and not even think that it may be on account of the fact that you are having the snoring,” she explained.

According to Dr Douglas, obstructive sleep apnea is also linked to heavy cigarette smoking, alcoholism, having a sedentary lifestyle.

Treatment

Dr Douglas said the risk factor modifications may only be helpful in the case of mild obstructive sleep apnea.

“You may be able to slow down progression or help it with moderate to severe, but when you have moderate to severe sleep apnea, they tend to move towards other forms of therapy,” she said.

She said in terms of risk modifications, patients are usually encouraged to change some of their lifestyle choices such as, adjusting alcohol intake, quitting smoking, improving diet, and incorporating exercise.

“Because the whole issue with obesity is that you have an increased fat deposition and this increase fat deposition in the neck actually narrows your airway, so if we can get rid of some of that, maybe that can help,” she explained.

She said that sometimes this approach helps, but for the most part, other forms of management have to be instituted.

Other forms of management include the use of a breathing machine which generates continuous positive airway pressure to help the patient breathe while sleeping.

“Normally when we take a breath in, our diaphragm, which is that muscle that separates our ribcage from our abdomen, that muscle contracts and allows us to take air in. We generate essentially a negative pressure.

“Now, because this negative pressure is generated, once again the airway is prone to collapse. But in normal persons and even persons with obstructive sleep apnea, once they are awake the patency of the airway is maintained because the muscle activity is increased and the muscle has its own intrinsic tone which is lost during sleep – so it is okay once you are awake,” Dr Douglas said.

But, once asleep, people with obstructive sleep apnea need a little more help keeping the airways open.

According to Dr Douglas, while taking these deep breaths in and generating this negative pressure, the negative pressure would creates like a suction effect and causes collapse of the airway, so the machine delivers a positive pressure which will help to keep the airway open.

She said the breathing machine appears to be the most effective treatment, because people who are compliant tend to have a reduction in the other major long-term sequelae of obstructive sleep apnea, especially as it relates to hypertension.

She saidf too that mandibular advancement devices are also mentioned in the treatment of obstructive sleep apnea, which essentially speaks to an attempt to pull the jaw forward, because when we fall asleep the tongue falls back, the jaw falls back and everything kind of closes off.

“So the whole idea is if we can try and nudge the jaw forward a little bit, maybe we can open the airway a little bit,” she explained.

And there is also surgical intervention.

Dr Douglas said it is also recommended that, for the most part, a patient should sleep on their side, which is what is called a lateral decubitus position.

“This may be more beneficial than sleeping on your back because once you start sleeping on your back, the airway falls backward and then you start being obstructed,” Dr Douglas said.